Medi-Cal Expansion and Children’s Well-Being

Technical Appendix

Paulette Cha and Shannon McConville With research support from Daniel Tan

PPIC.ORG Technical Appendix Medi-Cal Expansion and Children’s Well-Being 2

Review of Literature on Financial Security and Behavioral Health

Our report describes findings from a narrative literature review in the areas of financial security and behavioral health, which includes substance use disorder and mental health. All of the studies in the review analyzed a financial security or behavioral health outcome resulting from Medicaid or another health insurance expansion to low-income adults.1 Historically, most expansions of Medicaid and other public insurance programs targeted children. Expansions to adults, especially to adults without children, are a more recent phenomenon. Because of this history, and also because we prioritized recent evidence, most of the studies in our review focused on the ACA Medicaid expansion, with additional studies coming from other settings such as the Oregon Health Insurance Experiment and Massachusetts health reform.

We aimed to summarize causal evidence on adult outcomes as a foundation for generating hypotheses regarding child well-being. Associational studies of Medicaid are unlikely to capture a causal effect of the program, since Medicaid eligibility and program enrollment occur only among low-income individuals, and being low-income predicts a wide range of negative outcomes that should not be attributed to the program. Associational studies that compare Medicaid recipients with eligible non-enrollees still lack a comparable control group since there are many unobserved factors that determine enrollment in Medicaid that cannot be controlled for. In the case of the ACA, researchers have relied on the variation in states’ Medicaid expansion decisions and timing to conduct controlled quasi-experiments of Medicaid. If certain conditions are met, this approach provides estimates of causal or likely causal effects of the policy change. We focused our review on experiments and quasi-experiments, and excluded any purely associational studies.

Our narrative review included some features of a systematic review. We conducted searches for journal articles and reports in the PubMed database and on the Google Scholar website. The searches used the following words and phrases, plus some of their variants (different suffixes and abbreviations): Medicaid, expansion, Affordable Care Act, mental health, behavioral health, substance use disorder, serious mental illness, serious psychological distress, alcohol use disorder, finance, payment debt, bankruptcy, repossession. In order to be included, the studies needed to meet four criteria: (1) analyze a financial security or behavioral health outcome that is (2) the result of a health insurance expansion to (3) low-income adults using (4) methods that produce plausibly causal estimates. We also included work cited by the search-identified articles, as well as other studies that we encountered in our regular work dealings, if they met our conditions for inclusion.

This appendix contains two parts. Table A1 below summarizes studies published at time of writing in September 2019 that offer the strongest evidence about the effects of Medicaid or other health insurance expansions in the areas of adult behavioral health or financial security. The narrative review that follows summarizes findings for adult financial security and behavioral health. Throughout the review, we emphasize studies with research designs that are able to determine whether ACA Medicaid expansion and state expansions of insurance coverage for low-income adults, although we refer to studies from before the expansion and descriptive findings that provide important context.

1 For example, California’s Low Income Health Program (sometimes called “early ACA Medicaid”) and the Massachusetts state health reform.

PPIC.ORG Technical Appendix Medi-Cal Expansion and Children’s Well-Being 3

TABLE A1 Studies on the Effects of Medicaid (or Other Health Insurance) for Low-Income Adults on Financial Security and Behavioral Health * Abbreviations help connect listed studies to the outcomes column of Table 1 in the main report. MRE is medical-related expenses, NFS is negative financial shocks and debt, CSF is credit scores and future financial opportunities, MHI is specific mental health issues, MHS is access to mental health services, STX is access to treatment for substance use disorder, SUP is supply of substance use disorder treatment providers, and PAY is payer source for substance use disorder treatment.

Authors/Journal Outcomes* Title Setting High-Level Findings Main Data Source / Method Selected Details

Financial Security

Allen, Heidi L., Erica Eliason, Naomi Zewde, and Tal Gross 2019; Health Affairs

NFS Can Medicaid

Expansion Prevent Housing Evictions?

California: Early ACA Medicaid

Expansion (Low Income

Health Program)

Fewer evictions

Commercial evictions database from American Information Research Services; quasi-experimental (difference-in-

differences)

For every 1,000 enrollees in early Medicaid, there were 22 fewer evictions

per year.

Blavin, Fredric, Michael Karpman, Genevieve M. Kenney, and Benjamin D. Sommers 2018; Health Affairs

MRE, NFS

Medicaid Versus Marketplace Coverage for Near-Poor Adults:

Effects on Out-of-Pocket Spending and

Coverage

National: ACA Medicaid

Expansion

Lower out-of-pocket spending

Lower likelihood of high-burden spending

Current Population Survey and American Community Survey;

quasi-experimental (difference-in-differences)

Lower likelihood of having any out-of-pocket spending. Reductions in both

types of out-of-pocket spending: premiums and cost-sharing (e.g., copays). Lower likelihood of high-

burden (10 percent of income or more) out-of-pocket spending.

Brevoort, Grodzicki, and Hackmann 2017; N/A: National Bureau of Economic Research Working Paper

MRE, NFS, CSF

Medicaid and Financial Health

National: ACA Medicaid

Expansion

Reduced medical debt

Reduced new delinquencies

Improved credit scores

More offers of credit

Better terms of credit

Reduced bankruptcies

Consumer Protection Finance Bureau Consumer Credit Panel data; Mintel data, MyFico; quasi-

experimental (difference-in-differences)

Reduction of medical debt estimated to total $3.4 billion over the first two years

of the Medicaid expansion implementation. Types of credit offers

that increased include credit cards, personal loans, auto loans, and

mortgages. Better terms of credit (lower interest rates) estimated to total $520

million in annual savings.

Caswell and Waidmann 2017; Medical Care Research and Review

MRE, NFS, CSF

The Affordable Care Act Medicaid

Expansions and Personal Finance

National: ACA Medicaid

Expansion

Reduced medical debt

Reduced proportion of debt past-due

Improved credit scores

Reduced bankruptcies

Data from one of the three major credit reporting bureaus; quasi-

experimental (difference-in-differences and triple-differences)

Reduced the likelihood of any nonmedical collections balance, and

reduced the likelihood of having a medical collections balance of at least

$1,000.

Glied, Chakraborty, and Russo 2017; N/A: Commonwealth Fund report

MRE, NFS

How Medicaid Expansion Affected

Out-Of-Pocket Health Care Spending for

Low-Income Families

National: ACA Medicaid

Expansion

Lower out-of-pocket spending

Lower likelihood of catastrophic spending

Consumer Expenditure Survey; quasi-experimental (difference-in-

differences)

Lower odds of any out-of-pocket medical spending, and reduced

spending among those with nonzero spending.

Reduced likelihood of catastrophic medical spending (90th percentile or

higher).

continued

PPIC.ORG Technical Appendix Medi-Cal Expansion and Children’s Well-Being 4

Authors/Journal Outcomes* Title Setting High-Level Findings Main Data Source / Method Selected Details

Golberstein, Gonzales, and Sommers 2015; Health Affairs

MRE, NFS

California's Early ACA Expansion Increased

Coverage and Reduced Out-Of-

Pocket Spending for the State's Low-

Income Population

California: Early ACA Medicaid

Expansion (Low Income

Health Program)

Lower out-of-pocket spending

Lower likelihood of high-burden spending

National Health Interview Survey; quasi-experimental (difference-in-

differences)

Reduced the likelihood of having any out-of-pocket spending, and reduced

the likelihood of spending at least $500.

Hu, Luojia, Robert Kaestner, Bhashkar Mazumder, Sarah Miller, and Ashley Wong 2018; Journal of Public Economics

NFS

The Effect of The Patient Protection and

Affordable Care Act Medicaid Expansions

on Financial Wellbeing

National: ACA Medicaid

Expansion

Reduced number of bills sent to collections

Reduced amount of debt in collections

New York Federal Reserve/Equifax consumer credit panel;

quasi-experimental (synthetic control)

Number of bills in collections, and amount of debt in collections were

reduced, but other outcomes showed little effect. Credit card balance,

balance past due, credit score, total debt (including mortgages), and

bankruptcies showed little effect by the end of 2015.

Mazumder, Bhashkar, and Sarah Miller 2016; American Economic Journal: Economic Policy

NFS, CSF

The Effects of the Massachusetts Health Reform on Household

Financial Distress

Massachusetts: State Health

Reform

Reduced debt

Improved credit scores

Reduced bankruptcies

New York Federal Reserve consumer credit panel data, Small Area Health Insurance Estimates;

quasi-experimental (triple-differences)

The Massachusetts health insurance reform (a precursor to the ACA) improved credit scores, reduced

delinquencies, lowered the percent of debt past due, and reduced the

incidence of personal bankruptcy.

McMorrow, Stacey, Jason A. Gates, Sharon K. Long, and Genevieve M. Kenney 2017; Health Affairs

MRE

Medicaid Expansion Increased Coverage,

Improved Affordability, and Reduced

Psychological Distress for Low-income

Parents

National: ACA Medicaid

Expansion

Increased affordability

Reduced worrying about medical costs

National Health Interview Survey; quasi-experimental (difference-in-

differences)

Health services affordability increased. Reduced worry about costs were

concentrated among mothers.

Zewde, Naomi and Christopher Wimer 2019; Health Affairs

NFS, CSF

Antipoverty Impact of Medicaid Growing with State Expansions Over

Time

National: ACA Medicaid

Expansion

Reduced poverty rate in expansion states

Reduced likelihood of burdensome medical

expense

Current Population Survey Annual Social and Economic Supplement; quasi-experimental (difference-in-

differences)

The ACA Medicaid expansion pulled an estimated 690,000 individuals out of

poverty. The increase in medical costs over time results in a growing

antipoverty effect of Medicaid over time. Burdensome levels of medical spending

were defined as more than 10 or 20 percent of household resources.

Behavioral Health – Mental Health

Baicker, Katherine, Heidi L. Allen, Bill J. Wright, and Amy N. Finkelstein 2017; HealthAffairs

MHS

The Effect of Medicaid on Medication Use

Among Poor Adults: Evidence from Oregon

Oregon: Oregon Health

Insurance Experiment

Increased prescriptions for mental health

medications

Interview and health assessment data from the Oregon Health

Insurance Experiment; randomized control trial

Biggest increases in prescription drugs were medications for mental health

(mostly anti-depressants) and diabetes.

continued

PPIC.ORG Technical Appendix Medi-Cal Expansion and Children’s Well-Being 5

Authors/Journal Outcomes* Title Setting High-Level Findings Main Data Source / Method Selected Details

Baicker, Katherine, Heidi L. Allen, Bill J. Wright, Sarah L. Taubman, and Amy N. Finkelstein 2018; Millbank Quarterly

MHI, MHS

The Effect of Medicaid on Management of

Depression: Evidence from the Oregon Health Insurance

Experiment

Oregon: Oregon Health

Insurance Experiment

Increased diagnoses of depression

Decreased prevalence of undiagnosed

depression

Decreased untreated depression

Increased use of anti-depressants

Reduced symptoms of depression

Survey, interview, and health assessment data from the Oregon

Health Insurance Experiment; randomized control trial

Increased the chances of receiving a depression diagnosis among those without a pre-experiment diagnosis.

Also decreased prevalence of undiagnosed depression. Reduced the

share with untreated depression (no talk therapy or medication) and virtually eliminated untreated depression among

the group with a pre-experiment diagnosis. Increased the use of anti-

depressants and reduced the symptoms of depression.

Finkelstein, Amy, Sarah Taubman, Bill Wright, Mira Bernstein, Jonathan Gruber, Joseph P. Newhouse, Heidi Allen, Katherine Baicker, and Oregon Health Study Group 2012; Quarterly Journal of Economics

MHI

The Oregon Health Insurance Experiment: Evidence from the First

Year

Oregon: Oregon Health

Insurance Experiment

Improved self-reported mental health

Various administrative data sources and survey data from the Oregon

Health Insurance Experiment; randomized control trial

Improvements in self-reported mental health were measured as the number of

days of good mental health and the number of days not impaired by mental

health.

Golberstein and Gonzales 2015; Health Services Research

MHS

The effects of Medicaid eligibility on Mental Health Services and

Out-of-Pocket Spending for Mental

Health Services

National: Pre-ACA state

expansions of Medicaid to low-income

adults

No change to use of mental health services

Medical Expenditure Panel Survey-National Health Interview Survey linked data; quasi-experimental

(instrumental variables)

No significant increase in use of any mental health services, even when

focusing on a population with moderate-to-severe psychological

distress. Sample size could be a factor.

McMorrow, Stacey, Genevieve M. Kenney, Sharon K. Long, and Dana E. Goin 2016; Health Services Research

MHI, MHS

Medicaid Expansions from 1997 - 2009

Increased Coverage and Improved Access

and Mental Health Outcomes for Low-

Income Parents

National: Pre-ACA state

expansions of Medicaid to low-income

adults

Reduced unmet need for mental health care

Reduced psychological distress

National Health Interview Survey; quasi-experimental (instrumental

variables)

Reduced unmet need for mental health care due to cost. Reduced

psychological distress. Some of the analyses suggested that the immediate mental health benefits could fade over

time.

McMorrow, Stacey, Jason A. Gates, Sharon K. Long, and Genevieve M. Kenney 2017; Health Affairs

MHI

Medicaid Expansion Increased Coverage,

Improved Affordability, and Reduced

Psychological Distress for Low-income

Parents

National: ACA Medicaid

Expansion

Reduced worrying about medical costs

Reduced psychological distress

National Health Interview Survey; quasi-experimental (difference-in-

differences)

Reduced worry about costs were concentrated among mothers.

Reductions of psychological distress were concentrated among men.

continued

PPIC.ORG Technical Appendix Medi-Cal Expansion and Children’s Well-Being 6

Authors/Journal Outcomes* Title Setting High-Level Findings Main Data Source / Method Selected Details

Winkelman and Chang 2018; Journal of General Internal Medicine

MHI, MHS

Medicaid Expansion, Mental Health, and

Access to Care among Childless Adults with and without Chronic

Conditions

National: ACA Medicaid

Expansion

Improved self-reported mental health

Reduced diagnoses of depression

Behavioral Risk Factor Surveillance System; quasi-experimental (difference-in-differences)

Significantly reduced the reported number of poor mental health days and reduced depression diagnoses. These results were limited to the subgroup of

adults with chronic conditions.

Behavioral Health – Substance Use Disorder

Andrews, Christina M., Harold A. Pollack, Amanda J. Abraham, Colleen M. Grogan, Clifford S. Bersamira, Thomas D’Aunno, and Peter D. Friedmann 2019; Journal of Substance Abuse Treatment

PAY, SUP

Medicaid Coverage in Substance Use

Disorder Treatment after the Affordable

Care Act

National: ACA Medicaid

expansion

Increased role of Medicaid as payer for medication-assisted

treatment for substance use disorder

No change to supply of substance use

treatment programs

National Drug Abuse Treatment System Survey; quasi-experimental

(instrumental variables)

Increase in Medicaid-insured patients in outpatient treatment programs with medication-assisted treatment. No evidence that supply or capacity of

treatment programs increased.

Maclean and Saloner 2019; Journal of Policy Analysis and Management

STX, PAY

The Effect of Public Insurance Expansions

on Substance Use Disorder Treatment: Evidence from the

Affordable Care Act

National: ACA Medicaid

expansion

No change to admissions to specialty substance use disorder

treatment

Increased role of Medicaid as payer for

specialty substance use disorder treatment

Treatment Episode Data Set and Medicaid State Drug Utilization

Data; quasi-experimental (difference-in-

differences)

No evidence that Medicaid expansion changed admissions to specialty substance use disorder. Among

patients receiving specialty substance use disorder treatment, Medicaid

coverage and payments increased.

Meinhofer and Witman 2018; Journal of Health Economics

STX, SUP, PAY

The Role of Health Insurance on

Treatment for Opioid Use Disorders:

Evidence from the Affordable Care Act Medicaid Expansion

National: ACA Medicaid

expansion

Increased admissions to treatment for opioid use

disorder

Increased role of Medicaid as payer for

treatment for opioid use disorder

No change to supply of specialty treatment

facilities

Increased number of physicians with waiver

to prescribe buprenorphine

SAMHSA Treatment Epidose Data Set Admissions, Automation of

Reports and Consolidated Orders System (ARCOS), National Survey

of Substance Abuse Treatment Services; quasi-experimental

(instrumental variables)

Increased admissions to specialty treatment for opioid use disorder, most

of which involved outpatient medication-assisted treatment.

Admissions from Medicaid beneficiaries increased. More physicians with waiver

to prescribe buprenorphine and increased acceptance of Medicaid by substance abuse disorder providers.

continued

PPIC.ORG Technical Appendix Medi-Cal Expansion and Children’s Well-Being 7

Authors/Journal Outcomes* Title Setting High-Level Findings Main Data Source / Method Selected Details

Olfson, Mark, Melanie Wall, Colleen L. Barry, Christine Mauro, and Ramin Mojtabai 2018; Health Affairs

STX

Impact Of Medicaid Expansion On Coverage And

Treatment Of Low-Income Adults With

Substance Use Disorders

National: ACA Medicaid

expansion

No change to substance use disorder treatment

National Survey on Drug Use and Health; quasi-experimental

(instrumental variables)

No changes to substance use disorder treatment. Authors suggest some

population groups such as parents may have more incentives to enter

treatment.

Saloner, Brendan, Jonathan Levin, Hsien-Yen Chang, Christopher Jones, and G. Caleb Alexander 2018; JAMA Network Open

STX

Changes in Buprenorphine-

Naloxone and Opioid Pain Reliever

Prescriptions After the ACA Medicaid

Expansion

Selected States: ACA

Medicaid Expansion

Increased prescriptions for medication to treat

opioid use disorder

IQVIA prescription data; quasi-experimental (instrumental

variables)

Buprenorphine-naloxone prescriptions, which are used to treat opioid use

disorder, increased.

Wen, Hefei, Jason Hockenberry, Tyrone Borders, and Benjamin Druss 2017; Medical Care

STX, SUP

Impact of Medicaid Expansion on

Medicaid-Covered Utilization of

Buprenorphine for Opioid Use Disorder

Treatment

National: ACA Medicaid

expansion

Increased prescriptions for buprenorphine

Increased number of physicians with waiver

to prescribe buprenorphine

CMS Medicaid Drug Utilization Files; quasi-experimental (instrumental variables)

States that implemented Medicaid expansion saw a 70 percent increase in

Medicaid-covered buprenorphine prescriptions and a 50 percent increase in buprenorphine spending. Physician prescribing capacity also significant

associated with buprenorphine utilization.

PPIC.ORG Technical Appendix Medi-Cal Expansion and Children’s Well-Being 8

Financial Security Summary The Medicaid expansion lowered individual payments for health care and lessened the worries and barriers to care associated with those payments. Similar positive effects on family financial security have been shown for past expansions of Medicaid to children (Wherry, Kenney, and Sommers 2016). The ACA expansion to adults reduced self-reported difficulties in accessing health care for financial reasons, or in paying medical bills (Gunja et al. 2017; Long et al. 2017; Shartzer, Long, and Anderson 2016). It also reduced worrying about medical costs, especially among mothers (McMorrow et al. 2017). The Medicaid expansion lowered individuals’ costs for health services or prescriptions (Blavin et al. 2018; Glied, Chakraborty, and Russo 2017; Mulcahy, Eibner, and Finegold 2016; Long, Stockley, and Dahlen 2012). Results include reduced likelihood of having to spend any money on health care, and lower amounts paid by those who did spend (Glied, Chakraborty, and Russo 2017). Declines in spending were especially pronounced among those with chronic diseases, who have medical needs that cannot be ignored even when care is costly (Mulcahy, Eibner, and Finegold 2016). These national findings are consistent with evidence from an earlier, county-based ACA health insurance program in California called the Low Income Health Program, which reduced participants’ likelihood of having any health spending (Golberstein, Gonzales, and Sommers 2015). They are also consistent with research on older adults, whose health care spending declines when they become eligible for Medicare, a near-universal health insurance program for the elderly (Finkelstein and McKnight 2008; Barcellos and Jacobson 2015).

The Medicaid expansion protected individuals from a broad range of negative financial shocks. High levels of out-of-pocket spending, which are sometimes called “catastrophic” or “high-burden,” declined due to the Medicaid expansion (Blavin et al. 2018; Glied, Chakraborty, and Russo 2017; Goldman et al. 2018; Zewde and Wimer 2019). Reductions in catastrophic spending, combined with the fact that money not spent on medical bills can be reallocated to other family needs, presage the wider-reaching financial effects produced by expanded access to health insurance. Medicaid expansion produced declines in medical debt, especially in the poorest communities (Brevoort, Grodzicki, and Hackmann 2017). The program reduces both medical and non-medical bills in collections (Caswell and Waidmann 2017). Medicaid reduces the debt past-due, and decreases the likelihood of new financial delinquencies (Brevoort, Grodzicki, and Hackmann 2017; Hu et al. 2018). This affirms similar past findings from the Massachusetts health reform, a sweeping policy change that included health insurance expansion to adults (Mazumder and Miller 2016). There is evidence of a link between insurance access and the ability to afford housing. Recent studies find that California’s Low Income Health Program reduced evictions, and that the ACA tax subsidies for marketplace health insurance reduced mortgage delinquencies (Gallagher, Gopalan, and Grinstein-Weiss 2019; Allen et al. 2019).

Reductions in individual debts and delinquencies expand future financial prospects. Poverty levels declined in ACA expansion states (Zewde and Wimer 2019). Credit scores improved as a result of Medicaid expansion (Brevoort, Grodzicki, and Hackmann 2017; Caswell and Waidmann 2017). These findings are consistent with past work on the Massachusetts health reform (Mazumder and Miller 2016). Improved credit scores among low-income individuals lead to more credit offers on better financial terms. These offers include auto loans and mortgages, again signaling the far reach of Medicaid expansion on financial health (Brevoort, Grodzicki, and Hackmann 2017). In addition to improvements for the average affected person, there were also reductions in worst-case financial scenarios; specifically, bankruptcy filings decreased as a result of Medicaid expansion (Brevoort, Grodzicki, and Hackmann 2017; Caswell and Waidmann 2017).

PPIC.ORG Technical Appendix Medi-Cal Expansion and Children’s Well-Being 9

Behavioral Health Summary

Mental Health The strongest evidence for Medicaid’s effects on mental health care comes from the Oregon Health Insurance Experiment. The Oregon study found that Medicaid expansion led to improved reports of mental health status and also increased the number of diagnoses of depression and prescriptions for mental health drugs, of which the majority were anti-depressants (Finkelstein et al. 2012; Baicker et al. 2017; Baicker et al. 2018). The program reduced the share of individuals with untreated depression, and virtually eliminated untreated depression among those who had had a positive screening for the condition before the Medicaid study began (Baicker et al. 2018). Although access to mental health treatment was greatly improved as the result of the opportunity to apply for Medicaid in the Oregon experiment, the improvements appeared to be linked to the mental relief and financial reprieve associated with having health insurance, not necessarily to mental health treatment (Finkelstein et al. 2012; Baicker et al. 2018).

Findings on the use of mental health services from ACA expansion studies are more mixed. A study of depressed adults in three Medicaid expansion states found no post-expansion change in care utilization and no reported difficulty of making specialist appointments (Fry and Sommers 2018). Similarly, another study found no increase in the use of mental health services, even among a population with moderate-to-severe psychological distress (Golberstein and Gonzales 2015). In that case, small sample sizes may have limited the authors’ ability to detect changes. In contrast to these null findings, one larger study of the ACA found that a population with severe psychological distress or a history of substance use disorder was more likely to receive treatment in the ACA era (Creedon and Cook 2016).

Despite the mixed findings on utilization, improvements in mental health status were consistently found across national studies, and aligned with the Oregon findings. Medicaid expansion improved self-reported measures of mental health, including a reduction in the number of poor mental health days (Winkelman and Chang 2018). An earlier Medicaid expansion led to declines in psychological distress and reductions in unmet need for mental health care due to cost among low-income parents (McMorrow et al. 2016). The ACA Medicaid expansion reduced psychological distress, but this was likely due to improved financial security, since the use of mental health services did not increase (McMorrow et al. 2017).

In the area of behavioral health, there is strong evidence that Medicaid expansion improved mental health outcomes, increased access to treatment for opioid use disorder, and may have increased access to mental health services. These improvements to mental health may result as much from mental health care as from improved financial stability and reduced psychological distress caused by not having health insurance.2

Substance Use Disorder The findings on the effects of Medicaid expansion on substance abuse treatment are mixed, reflecting the fact that a lack of insurance is only one barrier to seeking treatment and improving outcomes among adults with substance use disorder. Expansion-related findings for substance use and its treatment are set against the backdrop of an overall decline in prescriptions for opioid pain medications, which occurred across all payers around the period of the policy rollout (Saloner et al. 2018). Medicaid expansion did not reduce opioid prescription beyond the national decline (Cher, Morden, and Meara 2019). Research to date finds no evidence that Medicaid expansion increased utilization of the general category of treatment for substance use disorder (Maclean and Saloner 2019;

2 Sometimes this is called the “warm glow” effect of health insurance.

PPIC.ORG Technical Appendix Medi-Cal Expansion and Children’s Well-Being 10

Olfson et al. 2018). This may be partially attributable to the fact that the supply and capacity of treatment facilities have not increased in expansion states (Andrews et al. 2019).

Positive findings for access to treatment are concentrated in the treatment of specific substances. Medicaid expansion increased admissions to specialty treatment for opioid use (Meinhofer and Witman 2018; Maclean and Saloner 2019). The expansion also increased the number of physicians with prescribing authority for buprenorphine, a medication used in the treatment of opioid use disorder (Knudsen et al. 2015). Buprenorphine prescriptions themselves increased as a result of the Medicaid expansion (Wen et al. 2017; Saloner et al. 2018). In addition, Medicaid expansion was associated with increased treatment for alcohol use disorder in Oregon (McCarty et al. 2018).

The expansion led to Medicaid taking on a larger role as a payer for the treatment of opioid use. Among Medicaid beneficiaries, buprenorphine prescriptions increased relative to other classes of drugs that are highly prescribed for this population (Cher, Morden, and Meara 2019). Medicaid coverage for those in inpatient opioid treatment increased (Meinhofer and Witman 2018; Maclean and Saloner 2019). Medicaid-paid outpatient medication-assisted treatment also increased (Andrews et al. 2019). However, increases in buprenorphine prescriptions occurred for all payers, not just Medicaid (Saloner et al. 2018). These combined results suggest that Medicaid may have increased access to medication-assisted treatment for the previously uninsured.

PPIC.ORG Technical Appendix Medi-Cal Expansion and Children’s Well-Being 11

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McMorrow, Stacey, Genevieve M. Kenney, Sharon K. Long, and Dana E. Goin. 2016. “Medicaid Expansions from 1997 to 2009 Increased Coverage and Improved Access and Mental Health Outcomes for Low-Income Parents.” Health Services Research 51 (4): 1347–67.

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